COVID-19 long-term toll signals billions in healthcare costs ahead

https://www.reuters.com/article/us-health-coronavirus-fallout-insight/long-term-complications-of-covid-19-signals-billions-in-healthcare-costs-ahead-idUSKBN24Z1CM?fbclid=IwAR2f9fSnhgGBVvIe1fKX2EO5kKSG7TwUesAMUGrG0jBSfoBrBYltR1e9Nik

COVID-19 long-term toll signals billions in healthcare costs ahead ...

Late in March, Laura Gross, 72, was recovering from gall bladder surgery in her Fort Lee, New Jersey, home when she became sick again.

Her throat, head and eyes hurt, her muscles and joints ached and she felt like she was in a fog. Her diagnosis was COVID-19. Four months later, these symptoms remain.

Gross sees a primary care doctor and specialists including a cardiologist, pulmonologist, endocrinologist, neurologist, and gastroenterologist.

“I’ve had a headache since April. I’ve never stopped running a low-grade temperature,” she said.

Studies of COVID-19 patients keep uncovering new complications associated with the disease.

With mounting evidence that some COVID-19 survivors face months, or possibly years, of debilitating complications, healthcare experts are beginning to study possible long-term costs.

Bruce Lee of the City University of New York (CUNY) Public School of Health estimated that if 20% of the U.S. population contracts the virus, the one-year post-hospitalization costs would be at least $50 billion, before factoring in longer-term care for lingering health problems. Without a vaccine, if 80% of the population became infected, that cost would balloon to $204 billion.

Some countries hit hard by the new coronavirus – including the United States, Britain and Italy – are considering whether these long-term effects can be considered a “post-COVID syndrome,” according to Reuters interviews with about a dozen doctors and health economists.

Some U.S. and Italian hospitals have created centers devoted to the care of these patients and are standardizing follow-up measures.

Britain’s Department of Health and the U.S. Centers for Disease Control and Prevention are each leading national studies of COVID-19’s long-term impacts. An international panel of doctors will suggest standards for mid- and long-term care of recovered patients to the World Health Organization (WHO) in August.

YEARS BEFORE THE COST IS KNOWN

More than 17 million people have been infected by the new coronavirus worldwide, about a quarter of them in the United States.

Healthcare experts say it will be years before the costs for those who have recovered can be fully calculated, not unlike the slow recognition of HIV, or the health impacts to first responders of the Sept. 11, 2001 attacks on the World Trade Center in New York.

They stem from COVID-19’s toll on multiple organs, including heart, lung and kidney damage that will likely require costly care, such as regular scans and ultrasounds, as well as neurological deficits that are not yet fully understood.

A JAMA Cardiology study found that in one group of COVID-19 patients in Germany aged 45 to 53, more than 75% suffered from heart inflammation, raising the possibility of future heart failure.

A Kidney International study found that over a third of COVID-19 patients in a New York medical system developed acute kidney injury, and nearly 15% required dialysis.

Dr. Marco Rizzi in Bergamo, Italy, an early epicenter of the pandemic, said the Giovanni XXIII Hospital has seen close to 600 COVID-19 patients for follow-up. About 30% have lung issues, 10% have neurological problems, 10% have heart issues and about 9% have lingering motor skill problems. He co-chairs the WHO panel that will recommend long-term follow-up for patients.

“On a global level, nobody knows how many will still need checks and treatment in three months, six months, a year,” Rizzi said, adding that even those with mild COVID-19 “may have consequences in the future.”

Milan’s San Raffaele Hospital has seen more than 1,000 COVID-19 patients for follow-up. While major cardiology problems there were few, about 30% to 40% of patients have neurological problems and at least half suffer from respiratory conditions, according to Dr. Moreno Tresoldi.

Some of these long-term effects have only recently emerged, too soon for health economists to study medical claims and make accurate estimates of costs.

In Britain and Italy, those costs would be borne by their respective governments, which have committed to funding COVID-19 treatments but have offered few details on how much may be needed.

In the United States, more than half of the population is covered by private health insurers, an industry that is just beginning to estimate the cost of COVID-19.

CUNY’s Lee estimated the average one-year cost of a U.S. COVID-19 patient after they have been discharged from the hospital at $4,000, largely due to the lingering issues from acute respiratory distress syndrome (ARDS), which affects some 40% of patients, and sepsis.

The estimate spans patients who had been hospitalized with moderate illness to the most severe cases, but does not include other potential complications, such as heart and kidney damage.

Even those who do not require hospitalization have average one-year costs after their initial illness of $1,000, Lee estimated.

‘HARD JUST TO GET UP’

Extra costs from lingering effects of COVID-19 could mean higher health insurance premiums in the United States. Some health plans have already raised 2021 premiums on comprehensive coverage by up to 8% due to COVID-19, according to the Kaiser Family Foundation.

Anne McKee, 61, a retired psychologist who lives in Knoxville, Tennessee and Atlanta, had multiple sclerosis and asthma when she became infected nearly five months ago. She is still struggling to catch her breath.

“On good days, I can do a couple loads of laundry, but the last several days, it’s been hard just to get up and get a drink from the kitchen,” she said.

She has spent more than $5,000 on appointments, tests and prescription drugs during that time. Her insurance has paid more than $15,000 including $240 for a telehealth appointment and $455 for a lung scan.

“Many of the issues that arise from having a severe contraction of a disease could be 3, 5, 20 years down the road,” said Dale Hall, Managing Director of Research with the Society of Actuaries.

To understand the costs, U.S. actuaries compare insurance records of coronavirus patients against people with a similar health profile but no COVID-19, and follow them for years.

The United Kingdom aims to track the health of 10,000 hospitalized COVID-19 patients over the first 12 months after being discharged and potentially as long as 25 years. Scientists running the study see the potential for defining a long-term COVID-19 syndrome, as they found with Ebola survivors in Africa.

“Many people, we believe will have scarring in the lungs and fatigue … and perhaps vascular damage to the brain, perhaps, psychological distress as well,” said Professor Calum Semple from the University of Liverpool.

Margaret O’Hara, 50, who works at a Birmingham hospital is one of many COVID-19 patients who will not be included in the study because she had mild symptoms and was not hospitalized. But recurring health issues, including extreme shortness of breath, has kept her out of work.

O’Hara worries patients like her are not going to be included in the country’s long-term cost planning.

“We’re going to need … expensive follow-up for quite a long time,” she said.

 

 

 

 

The Misguided Rush to Throw the School Doors Open

https://www.governing.com/now/The-Misguided-Rush-to-Throw-the-School-Doors-Open.html?utm_term=READ%20MORE&utm_campaign=The%20Misguided%20Rush%20to%20Throw%20the%20School%20Doors%20Open&utm_content=email&utm_source=Act-On+Software&utm_medium=email

With the COVID-19 pandemic raging across much of America, a return to full-scale classroom instruction poses too grave a risk to students, teachers, school staff, parents and their communities.

Across the country, many of the public schools that are scheduled to open their doors within the next few weeks are still in limbo as to whether they should open on time and how they should operate — with full-scale in-person classroom instruction, with online learning only, or with some hybrid of the two. But the right call is becoming clearer by the day: It’s too soon to bring students and teachers back into the classroom.

Most communities are not ready to reopen their schools for traditional classes because neither government leaders nor the public have done nearly enough to curb the spread of the coronavirus or make the necessary preparations that would be required to operate schools safely.

Tens of thousands of new cases of COVID-19 are being reported every day and the death toll is averaging more than a thousand daily, with Sun Belt states seeing most of the biggest surges. It’s becoming ever clearer that this grim tally will continue until an effective vaccine is available. Until then, the possibility that students, their parents, teachers and school staff could become infected with the coronavirus and spread it widely to their communities should gravely concern every public official. The danger is hardly speculative: Schools that are among the earliest to reopen are already seeing positive cases.

The arguments that students learn better in a classroom setting, that they are suffering psychologically from social isolation, and that school closures have been particularly hard on working families are all legitimate. But are we really prepared to further risk the health of our children and of our communities by putting them in an environment where most of the practices to curb the virus will be difficult, if not impossible, to consistently follow?

And the danger to school staff members if they are forced to return to work should not be underestimated. According to the Kaiser Family Foundation, 25 percent of teachers are at risk of serious illness if they become infected with COVID-19, either because of their age — 65 or older — or their underlying health conditions.

The rush to reopen fully for in-person instruction has been driven in part by President Trump and Education Secretary Betsy DeVos, whose demands have been accompanied with threats of losing federal funds. Those demands appear to run afoul of guidelines issued by the Centers for Disease Control and Prevention a few weeks ago: Among other things, the CDC counseled going with small, socially distanced class sizes, emphasizing hand hygiene and respiratory etiquette, and requiring cloth face coverings — common-sense precautions the president said were too strict and many school officials say will be difficult to implement.

The political pressure has been so intense that the CDC issued a new set of “resources and tools” for school reopening, with CDC Director Robert Redfield saying that “the goal line is to get the majority of these students back to face-to-face learning,” a stance that was seen by many as a capitulation after the president criticized the earlier guidelines. Clearly this is not what most Americans expect of our top health officials. The public must feel confident that decisions to reopen schools are based on the best scientific evidence available and the professional advice of educators.

Despite the threats and pressure, many school officials are still doing the right thing by listening to local health experts and deciding for themselves when and how best to reopen. I see this in my own state of Georgia, where, according to a recent Atlanta Journal-Constitution article on how Georgia schools plan to start the school year, most school official are delaying opening and say that when they do open they plan to implement a hybrid approach to instruction. “Teachers will check in virtually — via some video conferencing software allowing them to see the dozens of children they would normally engage with through rows or groups of desks,” the newspaper reported.

The larger school districts in metropolitan Atlanta recently reversed themselves from offering parents an option to send their children to school traditionally or attend virtually, opting to go all-virtual because of the spikes in the virus. Other schools in the state plan to meet on campus a few days a week and do virtual learning on other days. Then there are superintendents who plan to prioritize on-campus learning but restrict it to students with special learning needs, such as those who have autism. Many of these options are complex and carry with them implications difficult to foresee, but they all prioritize the health of students.

The ultimate decider of when schools will fully reopen will undoubtedly be parents, at least those who have the freedom and budgets to stay home and monitor their children’s academic progress and assist with their homework. As a caring society, we must ensure that the option to telework is given to as many parents as possible, so that the decision to send one’s children to school and possibly expose them to the coronavirus is not based on family income and social status.

We are still in an existential fight with the coronavirus, and we do not know precisely how or when this battle will end. We do know the virus is apolitical and knows no local or state boundaries. There are no quick or easy solutions. One can only pray that public officials learned something from reopening our economy too soon. We do not want this to happen again by prematurely reopening schools.

Much of what our children lose in a semester or two of distance learning can be made up in time, but a lost life is forever.

 

 

 

 

A Mississippi town welcomed students back to school last week. Now 116 are home in quarantine.

https://www.washingtonpost.com/nation/2020/08/06/school-coronavirus-outbreak-mississippi/?utm_campaign=wp_main&utm_medium=social&utm_source=facebook&fbclid=IwAR058o-kJ0UCs1SRJFdJ-bWJylbuVn1Q2QkYnhMpmWH4s6NVx9yN2CA6lNE

Over 100 students quarantined in Mississippi school district after ...

Last week, schools in Corinth, Miss., welcomed back hundreds of students. By Friday, one high-schooler tested positive for the novel coronavirus. By early this week, the count rose to six students and one staff member infected. Now, 116 students have been sent home to quarantine, a spokeswoman for the school district confirmed.

Despite the quick fallout, the district’s superintendent said he has no plans to change course.

As districts around the country debate the merits of in-person classes vs. remote learning amid an escalating novel coronavirus pandemic, the Corinth School District’s early experience shows how quickly positive tests can lead to larger quarantines.

Other districts that have welcomed teachers or students back have faced similar challenges. After teachers returned to plan lessons in Georgia’s largest district, 260 district employees were barred from reentering schools because of either testing positive for the coronavirus or being in close contact with someone who had. In southeast Kansas, six school administrators tested positive after attending a three-day retreat. And within hours of opening, a school in Greenfield, Ind., was informed by the health department that a student had the virus.

Some health officials in the Trump administration, which has pushed for schools to fully reopen, are now urging communities with high rates of the virus to rethink in-person classes. On Sunday, Deborah Birx, the White House’s top coronavirus coordinator, said on CNN’s “State of the Union” that in hard-hit areas, “we are asking people to distance-learn at this moment so we can get this epidemic under control.”

Mississippi has been among the hardest-hit states in the South and could overtake Florida as the top state for cases per capita, according to researchers at Harvard University. The state has had more than 63,000 coronavirus cases and more than 1,800 deaths to date.

On Tuesday, Gov. Tate Reeves (R) said in a Facebook post that he would delay school opening for seventh to 12th grades in hot spots. The governor also mandated masks in schools and ordered a two-week mask requirement for public gatherings.

In Corinth, the school district gave families an option of either sending their children to school buildings or doing distance learning from home.

“We made the decision that even though we had seen a spike in those numbers, that schools needed to reopen and at the same time, schools need to remain open,” Childress said in the Facebook Live broadcast.

According to the district’s reopening plan, students and teachers are screened daily, with their temperatures taken upon arrival at school and checked for symptoms including coughing, difficulty breathing, and loss of taste and smell. Childress said that the district will start midday temperature checks.

When the schools learned of positive coronavirus cases, they used contact tracing and notified students who had been “within 6 feet of an infected person for 15 minutes or more,” said a memo posted Wednesday on Facebook informing the community of the cases. Seating charts helped the school determine who needed to quarantine, Childress said in the Facebook Live broadcast.

Those students will have to self-quarantine for 14 days and continue school online.

Despite the positive tests and quarantines, Childress said he remained optimistic about the school district’s plans. He encouraged the families to wear masks, and he urged everyone with children in quarantine to stay home until getting their test results.

“We’ve had a good start of school,” Childress said. “We’re going to have some more positive cases. We know that. We know it will happen. We’re going to have to deal with it, and I can assure that we will deal with it and when we impose quarantines on students and staff, we are doing that for a reason.”

 

 

 

 

Fauci says family has faced threats, harassment amid pandemic

https://thehill.com/policy/healthcare/510709-fauci-says-family-has-faced-threats-harassment-amid-pandemic

Fauci says family has faced threats, harassment amid pandemic ...

Dr. Anthony Fauci, the nation’s top infectious disease expert, said he and his family are getting death threats because people don’t like what he says about COVID-19.

“Getting death threats for me, and my family, and harassing my daughters, to the point where I have to get security is just — I mean, it’s amazing,” Fauci said during an interview with CNN’s Sanjay Gupta on Wednesday.

“I wouldn’t have imagined in my wildest dreams that people who object to things that are pure public health principles, are so set against it and don’t like what you and I say, namely in the world of science, that they actually threaten you.”

He noted that crises like COVID-19 has brought out the best of people but also the worst of people.

Fauci’s notoriety has been elevated by COVID-19, as he is often on TV offering a blunt portrayal of the state of the pandemic in the U.S.

Fauci, 79, is one of the world’s most respected infectious disease experts, having advised six presidents on HIV/AIDS, Ebola, Zika and other health crises. He has earned a reputation for being blunt and willing to correct the president.

Fauci has had a security detail since at least April.

Fauci also reflected on what he says is a degree of “anti-science” sentiment in the U.S. that is making it difficult to get people to do things to slow the spread of COVID-19 like wearing masks.

“There is a degree of anti-science feeling in this country, and I think it is not just related to science. It’s almost related to authority and a mistrust in authority that spills over,” he told Gupta.

“Because in some respects, scientists, because they’re trying to present data, may be looked upon as being an authoritative figure, and the pushing back on authority, the pushing back on government is the same as pushing back on science.”

He said the scientific community should be more transparent and reach out to people to underscore the importance of science and evidence-based policy.

“I know when I say that if we follow these five or six principles, we can open up we don’t have to stay shut…There are some people that just don’t believe me or don’t pay attention to that. And that’s unfortunate because that is the way out of this,” he said.

President Trump has repeatedly undermined Fauci, questioning the White House coronavirus task force member on Twitter and in interviews with the media.

Over the weekend, Trump tweeted out a video of a portion of Fauci’s testimony explaining why the U.S. has recorded more cases than European cases and called it “wrong.” Trump has falsely claimed several times that the U.S. has more cases because it is doing more testing.

Trump has also retweeted multiple messages that question Fauci’s expertise, including one last week that said he had “misled the American public.”

 

Pandemic reveals flaws of unemployment insurance programs

https://thehill.com/policy/finance/510368-pandemic-reveals-flaws-of-unemployment-insurance-programs

Pandemic reveals flaws of unemployment insurance programs

The lapse of enhanced jobless benefits amid a record-breaking crush of applications is exposing the flaws and shortcomings of how the U.S. provides unemployment insurance.

The economic toll of the coronavirus pandemic has torn holes in a federal safety net woven by individual systems for every state plus the District of Columbia, Puerto Rico and the Virgin Islands. More than 30.2 million Americans were on some form of unemployment insurance as of mid-July, with the Labor Department reporting a growing number of new applications in subsequent weeks.

Friday’s expiration of a $600 weekly add-on to state benefits plunged those vulnerable Americans into financial peril.

Congressional Democrats and Trump administration officials are now deadlocked over negotiations for a broader coronavirus relief package that’s expected to include some form of federal unemployment benefits.

But short-staffed unemployment offices across the U.S. grappling with outdated technology and unprecedented demand would face challenges from implementing a scaled-down or more complicated approach to the weekly payments.

Economists and labor market experts also warn that any solution that emerges from the negotiations would take weeks, if not months, to get up and running, risking a potentially catastrophic fiscal cliff for tens of millions of U.S. households.

“You ought to be able to deliver the program that’s on the books,” said Douglas Holtz-Eakin, former director of the Congressional Budget Office and a White House economist under former President George W. Bush.

“The states, collectively, seem to have not kept up the systems and we now have a big problem because of that,” he added.

The unprecedented size and speed of the pandemic-driven economic collapse has posed a brutal challenge for state unemployment agencies. After 10 years of steady economic expansion, the labor market quickly went from the lowest unemployment rate in 50 years to the highest level of joblessness since the Great Depression.

New claims for unemployment benefits were averaging roughly 200,000 nationwide a week before the pandemic — a manageable level for state agencies that had largely been neglected during the longest stretch of growth in modern U.S. history. But the coronavirus lockdowns spurred 3.3 million new claims between March 15 and March 22, a then-record that would be doubled the following week. Before the COVID-19 outbreak, the previous record was 695,000 from the first week of October 1982.

A little more than four months after the pandemic hit, state agencies are now processing roughly 2 million new claims a week for both unemployment insurance and Pandemic Unemployment Assistance (PUA), a program designed to cover those who don’t qualify for typical benefits.

“On some level, you can’t really blame states for not being prepared for that level of onslaught,” said Michele Evermore, senior policy analyst at the National Employment Law Project.

“Usually, you see the recession starting up and state agencies say ‘You know, this looks like a recession here, so let’s start to staff up.’ This came on all at once, so we’ve had these neglected, antiquated systems and then there’s all these other stressors.”

The U.S. economy has been in recession since February, according to the National Bureau of Economic Research.

Processing the massive surge of unemployment claims on shoddy technology would have been hard enough for states. Adding enhanced benefits and PUA claims to the mix strained state agencies even more.

“It took time to upgrade those systems. It took time to hire and train new staff who could deal with the volumes of the calls, and all in a pandemic, when face-to-face contact and training and being together in office were not possible,” said Julia Pollak, labor economist at job recruitment and posting company ZipRecuriter.

“So it’s easy to see in hindsight why it all fell apart.”

Enhanced unemployment benefits are among the biggest obstacles to reaching a deal on what’s likely to be the last coronavirus relief package before the election. While President Trump and Republicans are divided over how and whether to extend the federal boost, Democrats are largely united behind extending the benefits and reducing them gradually along a curve tied to the unemployment rate.

Speaker Nancy Pelosi (D-Calif.) has called for including such a mechanism, known as an automatic stabilizers, in the coronavirus package being negotiated.

Rep. Don Beyer (D-Va.), vice chair of the Joint Economic Committee, introduced a separate bill designed to tackle economic downturns beyond the coronavirus recession. His measure would establish a six-tier system for reducing the federal benefit in line with a state’s unemployment rate.

The approach was endorsed by former Federal Reserve Chairman Ben Bernanke, who oversaw the central bank’s response to the Great Recession, and his successor, Janet Yellen.

“Every time you get close to a cliff and there’s a political battle and political price to be paid, probably by both sides, rather than just saying ‘This is what’s needed,’ let’s kick it in,” Beyer said in an interview.

“We talked to economists all across the country and virtually everyone we talked to said this makes the most sense.”

But Republican lawmakers and right-leaning economists have pushed back on efforts to codify mandatory spending and make decisions now about what will be needed to mitigate future crises.

“It’s hard for me to understand why it’s appropriate now to anticipate the economic conditions in the future and tie the hands of future elected representatives of Congress,” Holtz-Eakin said.

“It forked out $2.3 trillion in [the CARES Act] across the board in ways that got to small businesses, to households, to the employed, the unemployed. If you’re going to have one in 100-year events, that’s how you deal with them,” he added.

Republicans have instead proposed replacing the flat $600 weekly boost with a percentage of the worker’s pre-pandemic earnings in addition to what is prescribed by each state. While the wage-replacement is more tailored, Evermore warned that making the necessary calculations for each claimant could overwhelm an already teetering system.

“If you told states that they had to do a percentage replacement — oh, my gosh, that’s a recipe for crashing everything,” she said.

“It’s just not how the system is set up to work.”

 

 

 

 

40% of Americans still putting off care

https://www.axios.com/newsletters/axios-vitals-65b6b9b9-ee8e-4b89-9688-c43c0146c4d6.html?utm_source=newsletter&utm_medium=email&utm_campaign=newsletter_axiosvitals&stream=top

40% of Americans continue to put off medical care - Axios

Roughly 40% of Americans have postponed getting medical care due to the coronavirus outbreak. That number has stayed around 40% in all 12 weeks of the Census Bureau’s Household Pulse Survey.

Why it matters: Hospitals and doctors started rescheduling surgeries and other appointments as early as mid-May, and many patient volumes are mostly back to pre-pandemic numbers, Axios’ Bob Herman writes.

  • But this data suggests there is still a major backlog of Americans who need care — a phenomenon that existed well before the pandemic.

 

 

 

 

Admininstration believes Coronavirus is “under control”

https://www.axios.com/newsletters/axios-vitals-65b6b9b9-ee8e-4b89-9688-c43c0146c4d6.html?utm_source=newsletter&utm_medium=email&utm_campaign=newsletter_axiosvitals&stream=top

Daily confirmed COVID-19 cases, rolling 3-day average - Our World ...

President Trump said in an interview with “Axios on HBO” that he thinks the coronavirus is as well-controlled in the U.S. as it can be, despite dramatic surges in new infections over the course of the summer and more than 150,000 American deaths.

  • “They are dying, that’s true. And you have — it is what it is. But that doesn’t mean we aren’t doing everything we can. It’s under control as much as you can control it. This is a horrible plague,” he told Axios’ Jonathan Swan.

Reality check: The U.S. is averaging roughly 65,000 new cases and 1,000 deaths per day, Axios’ Sam Baker writes. The virus has already killed nearly 150,000 Americans, and it spread largely unchecked through almost the entire country throughout June and July.

The big picture: In the interview, which took place last Tuesday, Trump returned to familiar themes and areas where the U.S. really has made significant progress. He cited the dramatic increase in ventilator production, the ramp-up in testing and treatment that has reduced the overall fatality rate from the virus.

  • Yes, but: He painted a far rosier picture of the pandemic than most data would support.

On testing, Trump said, “You know there are those that say you can test too much” — a view that no experts have advocated.

  • The U.S. is experiencing long turnaround times for coronavirus testing, as Trump acknowledged, because of the high demand for testing. But that is largely a function of the country’s high caseload and the number of people at risk of infection.

He also returned to his mantra that “because we’ve done more tests, we have more cases.”

  • The cases the U.S. has, we would have had with or without testing. We know we have them because of testing, but the massive outbreak here would be a massive outbreak whether we chose to know about it (through testing) or ignore it by not testing.

 

 

 

 

The Mask Slackers of 1918

As the influenza pandemic swept across the United States in 1918 and 1919, masks took a role in political and cultural wars.

The masks were called muzzles, germ shields and dirt traps. They gave people a “pig-like snout.” Some people snipped holes in their masks to smoke cigars. Others fastened them to dogs in mockery. Bandits used them to rob banks.

More than a century ago, as the 1918 influenza pandemic raged in the United States, masks of gauze and cheesecloth became the facial front lines in the battle against the virus. But as they have now, the masks also stoked political division. Then, as now, medical authorities urged the wearing of masks to help slow the spread of disease. And then, as now, some people resisted.

In 1918 and 1919, as bars, saloons, restaurants, theaters and schools were closed, masks became a scapegoat, a symbol of government overreach, inspiring protests, petitions and defiant bare-face gatherings. All the while, thousands of Americans were dying in a deadly pandemic.

The first infections were identified in March, at an Army base in Kansas, where 100 soldiers were infected. Within a week, the number of flu cases grew fivefold, and soon the disease was taking hold across the country, prompting some cities to impose quarantines and mask orders to contain it.

By the fall of 1918, seven cities — San Francisco, Seattle, Oakland, Sacramento, Denver, Indianapolis and Pasadena, Calif. — had put in effect mandatory face mask laws, said Dr. Howard Markel, a historian of epidemics and the author of “Quarantine!

Organized resistance to mask wearing was not common, Dr. Markel said, but it was present. “There were flare-ups, there were scuffles and there were occasional groups, like the Anti-Mask League,” he said, “but that is the exception rather than the rule.”

At the forefront of the safety measures was San Francisco, where a man returning from a trip to Chicago apparently carried the virus home, according to archives about the pandemic at the University of Michigan.

By the end of October, there were more than 60,000 cases statewide, with 7,000 of them in San Francisco. It soon became known as the “masked city.”

“The Mask Ordinance,” signed by Mayor James Rolph on Oct. 22, made San Francisco the first American city to require face coverings, which had to be four layers thick.

Resisters complained about appearance, comfort and freedom, even after the flu killed an estimated 195,000 Americans in October alone.

Alma Whitaker, writing in The Los Angeles Times on Oct. 22, 1918, reviewed masks’ impact on society and celebrity, saying famous people shunned them because it was “so horrid” to go unrecognized.

“The big restaurants are the funniest sights, with all the waiters and diners masked, the latter just raising their screen to pop in a mouthful of food,” she wrote.

When Ms. Whitaker herself declined to wear one, she was “forcibly taken” to the Red Cross as a “slacker,” and ordered to make one and put it on.

The San Francisco Chronicle said the simplest type of mask was of folded gauze affixed with elastic or tape. The police went for gauze masks, which resembled an unflattering “nine ordinary slabs of ravioli arranged in a square.”

There was room for creativity. Some of the coverings were “fearsome looking machines” that lent a “pig-like aspect” to the wearer’s face.

The penalty for violators was $5 to $10, or 10 days’ imprisonment.

On Nov. 9, 1,000 people were arrested, The San Francisco Chronicle reported. City prisons swelled to standing room only; police shifts and court sessions were added to help manage.

“Where is your mask?” Judge Mathew Brady asked offenders at the Hall of Justice, where sessions dragged into night. Some gave fake names, said they just wanted to light a cigar or that they hated following laws.

Jail terms of 8 hours to 10 days were given out. Those who could not pay $5 were jailed for 48 hours.

On Oct. 28, a blacksmith named James Wisser stood on Powell and Market streets in front of a drugstore, urging a crowd to dispose of their masks, which he described as “bunk.”

A health inspector, Henry D. Miller, led him to the drugstore to buy a mask.

At the door, Mr. Wisser struck Mr. Miller with a sack of silver dollars and knocked him to the ground, The San Francisco Chronicle reported. While being “pummeled,” Mr. Miller, 62, fired four times with a revolver. Passers-by “scurried for cover,” The Associated Press said.

Mr. Wisser was injured, as were two bystanders. He was charged with disturbing the peace, resisting an officer and assault. The inspector was charged with assault with a deadly weapon.

That was the headline for a report published in The Los Angeles Times when city officials met in November to decide whether to require residents to wear “germ scarers” or “flu-scarers.”

Public feedback was invited. Some supported masks so theaters, churches and schools could operate. Opponents said masks were “mere dirt and dust traps and do more harm than good.”

“I have seen some persons wearing their masks for a while hanging about their necks, and then apply them to their faces, forgetting that they might have picked up germs while dangling about their clothes,” Dr. E.W. Fleming said in a Los Angeles Times report.

An ear, nose and throat specialist, Dr. John J. Kyle, said: “I saw a woman in a restaurant today with a mask on. She was in ordinary street clothes, and every now and then she raised her hand to her face and fussed with the mask.”

Suffragists fighting for the right to vote made a gesture that rejected covering their mouths at a time when their voices were crucial.

At the annual convention of the Illinois Equal Suffrage Association, in October 1918, they set chairs four feet apart, closed doors to the public and limited attendance to 100 delegates, the Chicago Daily Tribune reported.

But the women “showed their scorn” for masks, it said. It’s unclear why.

Allison K. Lange, an associate history professor at Wentworth Institute of Technology, said one reason could have been that they wanted to keep a highly visible profile.

“Suffragists wanted to make sure their leaders were familiar political figures,” Dr. Lange said.

San Francisco’s mask ordinance expired after four weeks at noon on Nov. 21. The city celebrated, and church bells tolled.

A “delinquent” bent on blowing his nose tore his mask off so quickly that it “nearly ruptured his ear,” The San Francisco Chronicle reported. He and others stomped on their masks in the street. As a police officer watched, it dawned on him that “his vigil over the masks was done.”

Waiters, barkeeps and others bared their faces. Drinks were on the house. Ice cream shops handed out treats. The sidewalks were strewn with gauze, the “relics of a torturous month,” The Chronicle said.

The spread had been halted. But a second wave was on the horizon.

By December, the San Francisco Board of Supervisors was again proposing a mask requirement, meeting with testy opposition.

Around the end of the year, a bomb was defused outside the office of San Francisco’s chief health officer, Dr. William C. Hassler. “Things were violent and aggressive, but it was because people were losing money,” said Brian Dolan, a medical historian at the University of California, San Francisco. “It wasn’t about a constitutional issue; it was a money issue.”

By the end of 1918, the death toll from influenza had reached at least 244,681, mostly in the last four months, according to government statistics.

In January, Pasadena’s city commission passed a mask ordinance. The police grudgingly enforced it, cracking down on cigar smokers and passengers in cars. Sixty people were arrested on the first day, The Los Angeles Times reported on Jan. 22, in an article titled “Pasadena Snorts Under Masks.”

“It is the most unpopular law ever placed on the Pasadena records,” W.S. McIntyre, the chief of police, told the paper. “We are cursed from all sides.”

Some mocked the rule by stretching gauze across car vents or dog snouts. Cigar vendors said they lost customers, though enterprising aficionados cut a hole in the cloth. (They were still arrested.) Barbers lost shaving business. Merchants complained traffic dropped as more people stayed home.

Petitions were circulated at cigar stands. Arrests rose, even of the powerful. Ernest May, the president of Security National Bank of Pasadena, and five “prominent” guests were rounded up at the Maryland Hotel one Sunday.

They had masks on, but not covering their faces.

As the contagion moved into its second year, so did the skepticism.

On Dec. 17, 1918, the San Francisco Board of Supervisors reinstituted the mask ordinance after deaths started to climb, a trend that spilled over into the new year with 1,800 flu cases and 101 deaths reported there in the first five days of January.

That board’s decision led to the creation of the Anti-Mask League, a sign that resistance to masks was resurfacing as cities tried to reimpose orders to wear them when infections returned.

The league was led by a woman, E.J. Harrington, a lawyer, social activist and political opponent of the mayor. About a half-dozen other women filled its top ranks. Eight men also joined, some of them representing unions, along with two members of the board of supervisors who had voted against masks.

“The masks turned into a political symbol,” Dr. Dolan said.

On Jan. 25, the league held its first organizational meeting, open to the public at the Dreamland Rink, where they united behind demands for the repeal of the mask ordinance and for the resignations of the mayor and health officials.

Their objections included lack of scientific evidence that masks worked and the idea that forcing people to wear the coverings was unconstitutional.

On Jan. 27, the league protested at a Board of Supervisors meeting, but the mayor held his ground. There were hisses and cries of “freedom and liberty,” Dr. Dolan wrote in his paper on the epidemic.

Repeal came a few days later on Feb. 1, when Mayor Rolph cited a downturn in infections.

But a third wave of flu rolled in late that year. The final death toll reached an estimated 675,000 nationwide, or 30 for every 1,000 people in San Francisco, making it one of the worst-hit cities in America.

Dr. Dolan said the story of the Anti-Mask League, which has drawn renewed interest now in 2020, demonstrates the disconnect between individual choice and universal compliance.

That sentiment echoes through the century from the voice of a San Francisco railway worker named Frank Cocciniglia.

Arrested on Kearny Street in January, Mr. Cocciniglia told the judge that he “was not disposed to do anything not in harmony with his feelings,” according to a Los Angeles Times report.

He was sentenced to five days in jail.

“That suits me,” Mr. Cocciniglia said as he left the stand. “I won’t have to wear a mask there.”

 

 

 

 

State of the Union: by Paul Field

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